Purpose: To analyze the indications, technique, results and complications of hysteroscopic myomectomy carried out in 291patients with the diagnosis of submucous myoma.
Patients and Methods: A retrospective survey of patients referred to the Video Service of Divina Providência Hospital and Moinhos de Vento Hospital, in Porto Alegre, RS, who had ultrassonographic and hysteroscopic clinical diagnosis of uterine submucous myoma and underwent hysteroscopy myomectomy. The procedure was carried out under anesthesia (spinal or epidural). A total of 316 submucous myoma patients were analyzed. Out of these, 291 underwent hysteroscopy myomectomy as an outpatient procedure, and 25 were excluded due to counterindication to endoscopy method, based on multiple intracavity myoma, uterine cavity larger than 10 cm (hysterometry), adenomyosis or clinical disease associated to the above mentioned factors. All patients underwent diagnostic hysteroscopy and endometrial biopsy to exclude concomitant malignant pathology. The indications, details of the technique, results and complications of the hysteroscopic myomectomy were evaluated.
Results: The age of the patients ranged between 30-54 years-old. The main indication for hysteroscopy myomectomy was the presence of abnormal uterine bleeding (menometrorrhagia). The surgical time was of approximately 25 minutes(15 – 45 minutes). Nine complications were documented. Post-surgery bleeding occured in 3 cases, uterine colon lacerations in 5 cases and moderate hypervolemy in 1 case. Most of the patients (97%) had the bleeding condition improved, but in 3% of them the bleeding persisted.
Conclusion: The management of submucous myoma can be done successfully via a videohysteroscopy approach with few complications, representing an alternative option for selected patients with this disease.
Introduction
Leyomyomas are the most common solid benign tumors of the female reproductive system. Uterine myomas occur in about 20% to 25% of women in reproductive age and in 40% of women older than 35 years-old. These tumors are caused by an hypersensitivity to estrogen of some myometrial cells (15) .
Myomas can cause menorragy, infertility, spontaneous abortion, premature labor and pelvic pain, depending on their size and localization. Submucous myoma are one of the causes for abnormal uterine bleeding and they can be associated to chronic endometryosis, besides presenting a higher malignization risk (leyomyossarcoma).
Various methods can be used in myoma diagnoses, namely:
ultrassonography, hysterossalpingography, computerized tomography, magnetic ressonance and videohysteroscopy. The first myomectomy was carried out in the 19th century; and Bonney has described the surgical technique, and published its results concerning uterus and fertility preservation as well as symptoms relief.
Trustworthy hysteroscopy techniques took place in the early seventies, mainly because of a better understanding of the methods employed for distending uterine cavity (1).
In 1978, Amin and Neuwirth (1) ressected the submucous myoma and the endometrium of a patient with abnormal uterine bleeding using a urological resectoscopy, describing the transcervical endometrial resection with an electric ring in a semicircle.
Presently, there are many myoma treatment techniques, namely: myolisis, embolization, myomectomy and hysterectomy. The employment of GnRh agonist made it the co-operative clinical therapy or short term clinical therapy. These agents provoke an hypoestrogenic state, reducing the myoma size. However, this effect is temporary; and, as the medication is interrupted it may grow again (7).
In their submucosal localization, myomas can be treated using exclusively surgical procedures, and they may be accessible by operative hysteroscopy – the standard surgical approach (14). The purpose of this survey was to evaluate the indications, technique, complications and results of the hysteroscopy myomectomy carried out in 291 submucous myoma patients.
Patients and Methods
Two hundred and ninety-one hysteroscopy myomectomies carried out at Divina Providência Hospital and Moinhos de Vento Hospital, in Porto Alegre, RS, were analyzed from March 1997 to June 2001. A total of 316 submucous myoma patients were analyzed. Out of these, 291 underwent hysteroscopy myomectomy
in the ambulatory, and 25 patients were excluded due to counterindication to endoscopy treatment, namely: multiple intracavity myomas, uterine cavity bigger than 10cm (hysterometry), adenomyosis, endometrial carcinoma and clinical disease associated to (serious cardiopathy or nephropathy) (Table 1).
The main indications for hysteroscopy myomectomy in our series are described on Table 2. The age ranged between 30-54 years old. The parity of the patients ranged from 0 to 5. All patients underwent pelvic examination, oncotic colpocitology, endovaginal ultrassonography and endometrium biopsy hysteroscopy. The latter was carried out in the pre-surgery period in order to confirm submucous myoma diagnosis, to plan the best surgical approach and to exclude atypic hyperplasy and endometrium adenocarcinoma.
In the pre-surgery evaluation the following examinations were carried out:
blood, blood platelet, fasting glicemy, creatinine, coagulation proofs, urine, electrocardiogram and thorax X-ray. GnRh agonist analogs: gosereline acetate – 3,75mg – 1 subcutaneous ampule/month or progestagen: Depo-Provera – 150 mg – 1 intramuscular ampule/month were used as pre-surgery medication in 82 patients for a period of 3 months in order to reduce the myoma volume, endometrium thickness and to improve surgical procedure. Pre-surgery medication was not used in 209 patients and the procedure was carried out in the first phase of menstrual cycle.
Out of 291 patients, 218 (75%) presented sessil submucous myoma.
Submucous myomas were hysteroscopically classified in three groups, (See Table 2 and figure 12). All patients underwent anesthesia (spinal or epidural). After cervical dilation was carried out with electric ring in semicircle. The instruments used were: Karl Storz, 26F ressectoscope with electric ring in semicircle and roller ball connected to a high frequency electric source, with 90 Watts of section and coagulation power.
The uterine cavity distension medium was the glicine 1,5%. The uterine cavity distension was achieved through hydrostatic pressure, and, in some cases, the electronic distensor Endomat (Karl Storz) was used. The glicine infusion speed was set in 250ml/minute; the intra-uterine pressure in 80 to 100mmHg and glicine aspiration pressure in 30 to 40 mmHg.
The surgical technique employed was the pediculum section on pediculated myomas and slicing with semicircle ring, in which the sight (ring) is moved inside out according to the manual ressectoscope mechanism. All patients were given prophilactic antibiotic: endovenous cefazoline or cefalotine – 2g in the trans-surgery period. In all cases, anatomo-pathological examination of taken material was carried out, as well as diagnosis hysteroscopy for post-surgery control in all patients 60 days after hysteroscopy myomectomy.
Results
The main indication for hysteroscopy myomectomy was abnormal uterine bleeding (Table 1). The surgical technique employed followed the principles recommended by literature for hysteroscopy surgery. Surgical time ranged from 17 to 20 minutes in the group of patients with pre-surgery medication, and from 25 to 40 minutes in the group with no medication.
In the group of patients with myoma types II and III (Table 3), 29 needed surgical treatment in two courses. Concerning abnormal uterine bleeding symptom (in 197 patients), most of them (191) - 97% - had this condition improved after hysteroscopy myomectomy and in 3% of them the bleeding persisted. These patients underwent hysterectomy.
Out of the patients who had indication for myomectomy due to infertility (74 patients), forty-eight (51%) got pregnant. Nine complications ensued: three patients with intensive post-surgery bleeding, which was controlled by setting an intra-uterine Foley for a 6 hour period, five intra-uterine colon lacerartions through Pozzi which required a suture with a 2-0 chromium-plated categut wire, one case of moderate hypervolemy, which was clinically treated, without further intercorrent facts.
leyomyoma diagnostic. During the post-surgery control (diagnostic hysteroscopy 60 days later) mucous uterine adherences were observed in 11 patients. These adherences were undone with the diagnosis instruments themselves.
Discussion
Surgical treatment of submucous myomas can be carried out using a ressectoscope, hysteroscopy scissors, versapoint (electrosurgical vaporization) or laser Nd:YAG (14) . Hysteroscopy scissors don't have hemostatic properties and can cause more bleeding. Versapoint and Laser, besides being more expensive, are not easily available.
The surgical approach by means of ressectoscope and high frequency power is the most used, allowing for data collection for the anatomo-pathologic survey. Pre-surgery preparation using analogs has been recommended by many authors in order to facilitate the procedure (18) . Besides reducing endometrial thickness, it reduces surgery time and hypervolemy risk.
The surgical technique which uses a ressectoscope with a ring eletrode allows an approach via myoma slicing and a better hemostatic control during trans-surgery.
Complications such as bleeding and hypervolemy were clinically treated without intercurrent facts. Patients who had had indication for myomectomy due to bleeding (197) achieved an improvement in 97% of the cases (191 patients).
These results are similar to the ones described in literature (14) .
A total of 6 patients (3%) who didn't show improvement in the bleeding symptom underwent hysterectomy and the anatomo-pathologic diagnostic confirmed adenomyosis. The hysteroscopy myomectomy is an ambulatory procedure, which allows patients to resume their physical and professional activities in 5 to 7 days in average.
This experience with 291 cases has shown that hysteroscopy myomectomy is a safe procedure, with few complications - when the right indications and techniques are observed - benefiting those patients who don't want or don't need to undergo hysterectomy. It can be concluded that submucous myoma surgical treatment through hysteroscopy is one more alternative approach to menorrhagy in selected patients.
Table 1. The inclusion and exclusion criteria for this study
_________________________________________________________________
Inclusion Criteria
- Submucous myoma patients confirmed by diagnostic hysteroscopy - Negative biopsy for endometrial hyperplasia or endometrium carcinoma
Exclusion Criteria
- Multiple (more than 2) submucous myoma patients - Uterine cavity bigger than 10cm – hysterometry - Associated adenomiosis
- Associated serious clinical disease (renal, hepatic, cardiac)
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Classification
type
Number of Patients
n ( %)
0 - Total intracavity myoma
132 ( 46 )
I- 50 % intracavity myoma
94 ( 32 )
II - 50% intracavity portion myoma
65 ( 22 )
Total 291 ( 100 )
Table 2 – Hysteroscopy classification of submucous myoma
Figure 16 – Classification Endoscopic of the myoma submucous
Type of indication
n ( % )
Abnormal uterine bleeding 197 ( 68 ) Infertility 94 ( 32 )
Total 291 ( 100 )
Table 3 – The indications of hysteroscopy miomectomy
Complications
n ( % )
Pos-operative bleeding 3 ( 33 ) Cervical laceration 5 ( 56 ) Hipervolemy 1 ( 11 ) Total 9 ( 100 ) Table 4 – Complications of the hysteroscopy miomectomy
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